![]() ![]() ![]() Association with national accrediting body reassures the public that all steps are being taken to prevent a recurrence.Īfter review of the accredited facility's report on the sentinel event, The Joint Commission issues an Official Accreditation Decision Report that may modify the organization's current accreditation status, assign an appropriate "measure of success", or a require follow-up survey within six months.Consultation with The Joint Commission on implementing the root cause analysis and action plan.Adding to the database with dissemination to other health care facilities, preventing other adverse events.Statistics of sentinel events are recorded and published by the FDA's MedWatch program.Īdvantages of reporting sentinel events to The Joint Commission are: In addition, healthcare organizations are required to notify the Food and Drug Administration (FDA) and device manufacturers within 10 days of a sentinel event caused by a medical device, according to the Safe Medical Device Act of 1990. However, the organization is expected to prepare a root cause analysis and action plan within 45 calendar days of the event. Each accredited organization is encouraged, but not required, to report any sentinel event to The Joint Commission. Potential improvements, called an "action plan", are identified and implemented to decrease the likelihood of such events in the future. ![]() Causal factors are analyzed, focusing on systems and processes, not individual performance. Participation is necessary by the leadership of TJC accredited healthcare organizations and by the persons closely involved in the systems under review. Main Sentinel Events reported to the Joint Commission in 2015 Type of event In addition to the list above, The Joint Commission requires each accredited organization to define sentinel events for its own care system and put into place monitoring procedures to detect these events and a procedure for root cause analysis.
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